1629083407 NPI number — PETER DANIEL JURISICH D.O.

Table of content: (NPI 1811169667)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629083407 NPI number — PETER DANIEL JURISICH D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JURISICH
Provider First Name:
PETER
Provider Middle Name:
DANIEL
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1629083407
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/28/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2 MEDICAL PLAZA DR STE 175
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROSEVILLE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95661-3049
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
916-782-2146
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2 MEDICAL PLAZA DR STE 175
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROSEVILLE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95661-3049
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-782-2146
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RC0001X , with the licence number:  20A8542 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RC0000X , with the licence number: 20A8542 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00AX85420 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1671625 . This is a "GREAT WEST" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 7450546 . This is a "AETNA" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 020A85420 . This is a "BLUE SHIELD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 2361104 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 4911481 . This is a "CIGNA" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 95883 . This is a "INTERPLAN" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 2121684 . This is a "FIRST HEALTH" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 90136861 . This is a "PACIFICARE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 000810778930 . This is a "PHCS" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 102287 . This is a "HEALTH NET" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 20A542 . This is a "BLUE CROSS" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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